Healthcare Provider Details

I. General information

NPI: 1891343505
Provider Name (Legal Business Name): ADRIENNE VANLEER ADA MARSH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E DOMINGUEZ ST
CARSON CA
90746-3600
US

IV. Provider business mailing address

1407 BRETT PL APT 102
SAN PEDRO CA
90732-5044
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-7755
  • Fax:
Mailing address:
  • Phone: 310-283-5794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: